So part of me is shocked that Toronto police didn’t handle the young man on the streetcar with a more subtle and humane approach.

Yet recent work I’ve done with the Canadian Patient Safety Institute taught me to look at these situations in a new light. Rarely are medical errors caused by individuals. Rarely is a single doctor or nurse the cause of patient harm.

Yet we assume so. Perhaps it is human nature to look for simple answers and a scapegoat.

Yet the patient safety community has matured beyond “shame and blame.” The causes of medical errors are typically systemic.

For example, two similar-sounding, but profoundly different drugs stored next to each other in a cabinet is an accident waiting to happen.

But most medical errors reveal a failure of systems, be they procedures, communications or even training.

The latter, training, seems particularly important in regard to police encounters with mental health patients in crisis.

The Edmonton Police Service, fortunately, has already started training its officers in dealing with mentally ill people.